Women's Studies International Forum 38 (2013) 52–62

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Women's Studies International Forum

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Spatial disparities and travel to freestanding in

Christabelle Sethna a,⁎, Marion Doull b a Institute of Women's Studies and Faculty of Health Sciences, University of Ottawa, 120 University (11030), Ottawa, , Canada K1N 6N5 b School of Population and Public Health, Faculty of Medicine, University of , 2206 East Mall, Room 414, , British Columbia, Canada V6T 1Z3 article info synopsis

Available online xxxx Access to abortion services is uneven throughout Canada. As a result, women cross provincial and territorial borders to garner access to abortion services. In this first-time study, the travel women undertake to access abortion services at freestanding clinics across the country was systematically tracked, mapped, and analyzed using questionnaire-based data. A total of 1186 women from 17 freestanding abortion clinics provided information about their journeys. The mapped data reflect the acknowledged importance of the “spatial turn” in the health sciences and provide a graphic illustration of spatial disparities in abortion access in Canada, namely: 1) the paucity of services outside urban centers; 2) the existence of substantial access gaps, particularly for women living in Atlantic, Northern and coastal communities; 3) the burdensome costs of travel and, in some cases, the costs of the abortion procedure itself, especially for younger women who travel the farthest; 4) the unique challenges First Nations and Métis women face in accessing abortion services. © 2013 Elsevier Ltd. All rights reserved.

Introduction comprehensive and publicly administered nationwide (Singh Bolaria & Dickinson, 2001). Although the overall intent of the Abortion in Canada was legalized in 1969 but under very Act is to create a system of equitable access to health care, restrictive conditions. The Supreme Court struck down this have raised concerns about “timely access to law in 1988. Since then, Canada remains one of the few existing services, particularly in rural and remote areas, countries in the world without a federal law regulating limited progress in advancing primary health care reforms abortion. Today, abortion is considered a “medically neces- and growing wait lists, especially for diagnostic services” sary” service. This phrase has various interpretations; it has (Final Report of the Commission on the Future of Health Care not been defined federally but it generally means a service in Canada, 2002). However, access to abortion services rarely performed by a physician as defined by the Canada Health figure in such national concerns despite the fact that it is Act or a service a patient needs “in order to avoid a negative uneven throughout the country and has been described as a health consequence” (Charles, Lomas, & Giacomini, 1997: “patchwork quilt with many holes”(Eggertson, 2001: 847). 365–94). In Canada, health care is administered by provincial The most recent data available suggest that Canadian or territorial governments but the federal government holds women are obtaining fewer than in previous years, sway by allocating funds to provinces and territories for and this decline is most apparent among young women health care purposes. The federal government is also under the age of 20 years (Statistics Canada, 2008a). It is responsible for enforcing the . This Act speculated that the drop in abortion is due in part to sets out five principles of public, universally funded Medi- decreased sexual activity among young people and increased care. Health care must be accessible, portable, universal, contraceptive use (Rotermann, 2008; Santelli, Linbderg, Finer, & Singh, 2007). However, abortion rates are also ⁎ Corresponding author. closely tied to the accessibility of the procedure (Jones &

0277-5395/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.wsif.2013.02.001 C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62 53

Kooistra, 2011). Data on abortion access in the study (n=26).1 Seventeen out of 26 clinics agreed to have indicated the rise and fall of abortion rates among participate; every province with a freestanding abortion neighboring states when restrictive policies are introduced was represented in the study, namely Newfoundland and (Santelli et al., 2007) Studies show that the further a women Labrador, New Brunswick, , Ontario, , Alberta, has to travel to access abortion, the less likely she is to obtain and British Columbia. The province of one and the more likely she is to be young and underpriv- (PEI) has no hospital or clinic facilities for abortion services. In ileged (Jewell & Brown, 2001; Lichter, McLaughlin, & Ribar, the northern Canadian territories (Northwest Territories, 1998; Shelton, Bran, & Schultz, 1976). Legal or extra-legal and ), in Nova Scotia and Saskatchewan obstacles can restrict access to abortion services. Extra-legal abortion access is hospital-based only (see Table 1). In the obstacles may include institutional policies regulating the urban centers of , Montreal and Vancouver, where the delivery of abortion services, the costs of the procedure, the majority of the country's freestanding abortion clinics are imposition of gestational limits, the lack of confidentiality, concentrated, more than one clinic participated. The most anti-choice harassment and violence, and the location of common reason for non-participation was limited staff re- abortion services (Farid, 1997; Gober, 1994; Henshaw, 1991; sources to commit to the study. Palley, 2006). Data were collected using a self-administered written In Canada, these extra-legal obstacles have coincided with questionnaire intended to track, map and analyze women's a steady drop in public sector hospitals performing abortions journeys to clinic abortion services. The questionnaire was since 1977 (CARAL, 2003; Report of the Committee on the previously tested in the pilot study and was slightly revised Operation of the , 1977; Shaw, 2006). Currently, for the national study (Sethna & Doull, 2007). It was available only 15.9% of hospitals in Canada offer abortion services and in four languages, English and French as well as Cantonese the majority of these hospitals are located in urban centers and Punjabi, the latter two languages common to urban (Shaw, 2006). Freestanding abortion clinics exist apart from immigrant populations and recommended by clinic stake- hospitals, operate in the public, semi-private and/or private holders. Questions posed related to demographics (age of sectors and are based mainly in urban centers. Such clinics respondent, marital status, nationality, self-defined ethnicity, have become attractive options even though private health mother tongue, place of residence, postal codes, employment care services may disadvantage women because they are less status), logistics (distance travelled, mode of transportation, likely able to pay for them (Rodgers, 2006) and private health expenses incurred), and experiences (reasons for choosing care services have become contested ground in Canada for the clinic and assessment of the ease or difficulty of their federal, provincial and territorial powers in an era of financial journey). cutbacks, increased demand for public health care services, The questionnaire was distributed for one month at each and proposals for the reform of (Browne, 2004; participating clinic. The national study was approved by the Pro-Choice Action Network, 2002; Taylor, 2006). As a result, Canadian women attempt to find spatial Table 1 solutions to an unwanted pregnancy, crossing provincial and Locations of freestanding clinics and hospitals with abortion access. territorial borders to garner access to abortion services in Province/ No. of freestanding No. and percentage jurisdictions outside their home communities. Despite the territory clinics and location of hospitals providing importance of such travel to access abortion services, the abortion servicesa topic has been largely ignored (Palmer, 2011; Sethna, 2011; British 4 (Vancouver, 26 (29% of hospitals in province) Sethna & Doull, 2007), underlining the neglect of abortion as Columbia Victoria) a medically necessary service for women in Canada (Fowler & Alberta 2 (Edmonton, 6 (6% of hospitals in province) Trouton, 2000; Norman, 2011). In this first-time study, we Calgary) attempt to fill this knowledge gap by systematically tracking, Saskatchewan 0 4 (6% of hospitals in province) Manitoba 1 () 2 (4% of hospitals in province) mapping and analyzing the travel women undertake to Ontario 8 (Toronto, 33 (17% of hospitals in access abortion services at freestanding clinics throughout Ottawa) province), only one in Northern Canada. Ontario Quebec 9 (Montréal, 31 (24% of hospitals in province) Methodology Trois Rivières, Gatineau, Our national study was informed by a regional pilot study Rimouski) conducted on women's travels to the Toronto Morgentaler New Brunswick 1 (Fredericton) 1 (4% of hospitals in province) Clinic, a freestanding abortion clinic that operates in the Nova Scotia 0 4 (13% of hospitals in province) Prince Edward 0 0 (no access) public sector in Toronto, Ontario. The findings from the pilot Island study revealed that women were travelling considerable Newfoundland/ 1 (St. John's) 3 (21% of hospitals in province) distances to access abortion services at this clinic. Moreover, Labrador women from lower income groups were more likely to have Yukon 0 1 (50% of hospitals in territory) travelled further to access abortion services and younger Territory Northwest 0 2 (67% of hospitals in territory) women were more prone than older women to report their Territories journey to the clinic as “difficult” (Sethna & Doull, 2007). Nunavut 0 1 (100% of hospitals in territory) The pilot study prompted the need for a national study of Territory travel to freestanding abortion clinics. All freestanding a Source: Shaw J. (2006). Reality Check: A close look at accessing abortion abortion clinics were invited to participate in this national services in Canadian hospitals. Ottawa: Canadians for Choice. 54 C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62

University of Ottawa Ethics Board. The clinic's intake officer exported to Adobe Illustrator for legend creation and carto- offered the questionnaire to women upon their entry into the graphic improvements. clinic. The officer explained that participation in the study was voluntary and that the questionnaire was anonymous. Results Women who agreed to participate filled out the question- naire while they were waiting to be seen by clinic staff and A total of 1186 women participated in the national study. The then returned the completed questionnaires to the intake average age of participants was 26.0 years (s.d., 6.4). The ages of officer. For confidentiality purposes, the questionnaire did the participants ranged from 12 to 48 years with 0.5% of the not require the respondent to report her name and an opaque sample under 16 years old and 14.6% under 20 years old envelope was used to submit her answers. The women's (Table 2). Over 60% of the participants reported that they comments are reproduced verbatim. made less than $30,000 per year (60.5%), 23.8% earned less than $10,000 per year and 9.7% were receiving social assistance. Most were Canadian born (76.7%) and self-identified as “white” Analysis (64.3%). However, because the questionnaire allowed partici- pants to self-identify their ethnicity there were 187 distinctive Analysis was completed using SPPS (version 18.0). Simple responses that were sorted into eight broad groups for counts and percentages were calculated for most variables. analysis (Table 2). Each group captured an array of responses. Where possible, odds ratios with 95% confidence intervals were For example, participants self-identifying as African, African calculated to quantify trends. Given the acknowledged impor- American, African Canadian, Black, Congolese, Ethiopian, Haitian, tance of the “spatial turn” in the social sciences, the humanities and more recently in the health sciences (Dunae, 2008; Pickles,

1999), data emerging from the questionnaires were mapped to Table 2 provide a graphic illustration of women's travel patterns to Demographic characteristics. abortion clinics. Public health practitioners have long used maps Age % to explain complex health issues stemming back to John Snow's 12–16 years 2.3 1854 map that pinpointed a water pump as the source of a 17–20 years 19.5 London cholera epidemic (Kreiger, 2009). Today, maps are used 21–25 years 33.0 increasingly to provide visual evidence of spatial disparities and 26–30 years 21.5 – can be a powerful tool to illustrate the variable geographic 31 35 years 13.4 36–40 years 7.6 impact of health care policies (Geraghty,Balsbaugh,Nuovo,& 41–48 years 2.8 Tandon, 2010; Nykiforuk & Flaman, 2011; Ruiz-Muñoz, Pérez, Employment status Gotsens, & Rodríguez-Sanz, 2012). Canadian Census Divisions Unemployed 16.7 (CDs) were selected as the primary unit of analysis to provide a Full-time 52.2 Part-time 17.3 high-level overview of patient home community locations Full-time student 11.5 appropriate for national as well as provincial scale visualization. Part-time student 2.4 A census division is defined as “a group of neighboring Race/Ethnicity municipalities joined together for the purposes of regional White 64.3 planning and managing common services” and can correspond Asian 4.9 South Asian 5.3 to a or a regional district depending on the province or Black 8.6 territory (Statistics Canada, 2006). In total, patients travelled First nations/Métis 7.4 from 121 of the 288 CDs in Canada. Additionally, this aggregation Middle Eastern 1.8 was selected to ensure that no individual patients could be Latina 1.6 Mixed race 2.9 identified within smaller geographic units. The mapping Relationship status database creation process began by geocoding patients' self- Single 23.1 reported home postal codes (95.6% of participants provided a Boyfriend/partner 59.3 postal code) using DMTI GeoPinpoint and then locations were Married 13.9 spatially joined to CDs using boundary files created by Statistics Separated 2.1 Divorced 1.5 Canada in 2006. Summary statistics were calculated by aggre- Widowed 0.1 gating all patient information within each CD. Aggregated data Income for each CD were then linked to the geographic centroid of each Less than $10,000 23.8 CD and visualized using the proportional symbol tool available $10,000–$19,999 23.3 $20–29,999 18.2 in ESRI ArcMap 10 software. All data for CDs with less than five $30–39,999 14.6 patients were scaled up to be equivalently sized to a CD with 5 $40–49,999 8.1 patients to ensure clear visualization and protection of privacy. $50–59,999 5.0 To produce the maps from these data and visualize patient Over $60,000 7.1 travel patterns, study clinic locations were first geocoded as Education None 2.3 above using the address locations. Straight lines were produced Elementary 0.8 to depict women's travel patterns from each CD to the clinic High School 38.9 using ArcMap software. All files were then projected into College 32.5 Canada Albers Equal Area Conic to ensure land areas and University, undergraduate 17.8 University, graduate 7.8 distances are accurately represented. Finally, each map was C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62 55

Nigerian, Somali were grouped into “Black”; those self- the phone”; “phone always busy”; “they never returned my identifying as Arab, Lebanese, Syrian were grouped into “Middle calls”), cost (e.g., “clinic did not take OHIP [Ontario Health Eastern.” These broad groups do not capture the diversity of the Insurance Plan]”, “wasn't expensive but it was $50 and don't responses but they do reflect the ethnic diversity of the Canadian have that at the moment”), requirements for an ultrasound and population. Nearly 82% of participants lived within 100 km of a resultant delays (e.g., “they insisted on an ultrasound first which clinic located in or near an urban center while 18.1% lived over I could not get for 3 weeks”), logistical difficulties posed by the 100 km from a clinic. The distance to a clinic varied from less journey to the clinic (e.g., “Iwasn'tsurehowtogetthereby than 1 km to 3,558 km (for a national snapshot of travel patterns public transportation”; “they [clinic staff] would not let me take a see Fig. 1). Figure one also reveals that many women bypass taxi”) and, the unavailability of medical as opposed to surgical hospital-based abortion services in or near their home commu- abortion (e.g., “I was referred here because the other place does nities in favor of freestanding clinics. As this study focused solely not do medical abortions”). on freestanding clinic-based access we did not gather data on In Toronto, Montreal and Vancouver, where women can women's contact with hospitals or reasons for selecting a clinic access abortion services at several freestanding clinics as well over a hospital. However, we know that some women (19.2%) as hospitals, the proportion of women travelling more than reported that the clinic they visited was not the first clinic they 100 km to clinics ranged from 0% to 12%, reflecting their contacted. The most common reason they gave for contacting an proximity to abortion services (see regional maps, Figs. 2–5). In additional clinic was the absence of appointments at the first contrast, seventy-three percent of women travelling to the clinic contacted (39.9%). Others stated that the first clinic they clinic in New Brunswick travelled more than 100 km to access called was too far from their home (11.8%) or the staff was rude services and approximately a third of women (29–36%) on the phone (11.4%). A sizeable number of women cited “other” travelling to clinics in Alberta, Manitoba and Vancouver Island reasons (35.5%) for not visiting the first clinic they called. Their travelled more than 100 km to access services. Alberta has hand-written comments indicated that they were discouraged clinics in its two biggest cities, Calgary and Edmonton, by long wait times (e.g., “appointment was too far away, long Manitoba has one clinic in its capital, Winnipeg, and Vancouver wait time”), gestational limits (e.g., “grosses trop avance pour Island has one clinic in its largest center, Victoria. Given l'hopital, 14.6 semaines [de la grossesse] referee a la Clinique Canada's vast size and its cluster of populations in Atlantic, Morgentaler”2; “I was too early in the pregnancy”), difficulties northern and rural areas, distances travelled can be consider- getting through to the clinic by phone (e.g., “no one answered able. For example, there is a substantial population living in

Fig. 1. National map of women's travel patterns to access abortion services. 56 C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62

Fig. 2. Regional map of women's travel patterns to abortion clinics — British Columbia and Alberta. northern Alberta due to lure of the oil and gas industry. This (65.7%) mentioned costs of $50–$100 which suggests, area is approximately 450 km from Edmonton and 755 km according to clinic fee schedules, that they paid for supple- from Calgary. mentary expenses such as administrative fees, medication or Just under half the participants (44.9%) travelled an hour follow-up contraception rather than for the abortion proce- or more to the clinic where they accessed abortion services dure itself. Administrative fees that clinics may charge range with 52.8% of these women stating that this clinic was closest from $60 to $100 (CDN). Clinic fee schedules indicate that the to their home. Again, in many of these cases, women abortion procedure can cost anywhere from $370 to $1300 bypassed a nearby hospital-based abortion service. Women's (CDN) with costs depending on whether the women is from reported travel costs varied from “nothing” (15.6%) to out of the province or country and by . The more than $100 (CDN) (5.4%). When asked to detail their 25.3% of women who reported paying more than $300 likely transportation costs women reported paying for plane paid for the abortion procedure itself. Whether or not these tickets, bus tickets, gas for vehicles, ferries and taxis, often women would later be reimbursed by their provincial for themselves and a travel companion. In addition to travel government health care plans for the abortion procedure is costs, some women (38%) incurred other expenses that unknown. The majority of those women who did not pay ranged from less than $10 (CDN) (9.5%) to more than $100 for their abortion procedure reported that they used (CDN) (3.1%). These expenses varied but included childcare, their provincial health care plan cards and noted that their car repairs prior to travel, parking costs, food and loss of procedure was paid by their own provincial health care income due to time off work. Costs were often doubled as the system (93.3%). majority of women reported travelling to the clinic with Several important spatial disparities emerged in relation someone (73.1%), most often a boyfriend/partner (42.3%), to the age, ethnicity and geographic location of the partici- friend (24%) or husband (15.2%). pants. Women under the age of 30 were more likely to have Although abortion is supposedly a funded, medically travelled over 100 km to access a clinic (OR=1.57 [95% CI: necessary procedure, 22.1% of women reported that they 1.08, 2.28]) (see Fig. 6 for an illustration of travel patterns by paid for their own abortions. Of these women, 19% paid for age) and were also almost twice as likely to report that their the abortion procedure and for travel to the clinic. The bulk of journey to the clinic was “difficult” (OR=1.83 [95% CI: 1.06, the women who reported paying for their abortion procedure 3.15]) compared with women over the age of 30. Women C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62 57

Fig. 3. Regional map of women's travel patterns to abortion clinics — Saskatchewan and Manitoba. who self-identified as First Nations or Métis were almost stressed being late), staff very efficient and physician three times more likely to report travelling over 100 km to excellent; caring environment.” access a clinic as compared with white women (OR=0.33 “Accessible to bus or transportation”“All the staff at the [95% CI: 0.20, 0.53]). Not surprisingly, these women were also clinic are great. They make you feel comfortable and at more likely to report that their journey was difficult as ease about the situation. The clinic is only 2 minutes drive compared with white women (OR=0.41 [95% CI: 0.22, from my house.” 0.79]). Women who lived more than 100 km from a clinic “Icamewithafriend,itwasfairlyeasytofind and there were also more likely to report that they would have were no [anti-abortion] protestors here.” preferred to have their abortion earlier compared with “Because I was already comfortable with my decision and it women living less than 100 km from a clinic possibly was easy to get to, except the parking was difficult to find.” reflecting delays or hardships created by travel (OR=0.67 [95% CI: 0.48, 0.93]). More than one quarter of the sample (28.2%; n=329) Finally, despite the considerable distances travelled in reported that their journeys were easy because, having been to some cases, the majority of women in this study stated that same clinic for a previous abortion, they were familiar with the their journey to the clinic was “easy.” Most illuminating were route. There were no significant patterns by age or income the narrative responses to the open-ended question which when this variable of a previous abortion was examined; asked women to describe why they felt their journey to the however, women who self-identified as First Nations or Métis clinic was “easy” or “difficult.” were more likely to report a previous abortion as compared Those who described an easy journey focused on logistical with white women (OR=0.52 [95% CI: 0.32, 0.84]). reasons such as accurate directions from the clinic and good Women who described a difficult journey similarly high- public transit to the clinic. Supportive staff, no anti-abortion lighted logistical reasons such as a time-consuming travel, protestors at the clinic and a positive sense of their decision costs or complicated arrangements: to abort were also cited: “I had to travel 8 hours the day before so that I was at the “Office was easy to locate, gave myself enough time to hospital in time this morning and I have to drive 8 hours arrive a few minutes early (therefore not rushed, not back today.” 58 C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62

Fig. 4. Regional map of women's travel patterns to abortion clinics — Ontario and Quebec.

“It was expensive to travel, very difficult to arrange and, in some cases, the costs of the abortion procedure itself, transportation and accommodations.” especially for younger women who travel the farthest; 4) the unique challenges First Nations and Métis women face in They also expressed tensions associated with the journey, accessing abortion services. the pregnancy and the abortion procedure itself: Urban centers serve women best because of the existence of numerous freestanding abortion clinics (and hospital-based “Because I feel very sick. My body is feeling very bad. I am a abortion services) available to them, increasing the chances of a physical and emotional wreck.” timely appointment in a location that is reached easily, quickly “Emotional. I'm going through a lot right now and this is just and at low cost. The concentration of abortion clinics in these something to add to the list. I am very stressed out and I am centers explains why women who live at a distance must travel hoping things get better soon.” to access abortion services. Importantly, the maps indicate that “Far from home. Got lost on the way. Feeling emotionally in many cases women from outside urban centers bypass and psychologically uneasy.” hospital-based abortion services in or near their home commu- “It is emotionally and psychologically uncomfortable be- nities in favor of freestanding abortion clinics. Hospital-based cause the long wait period [for an abortion] causes anxiety abortion services are essential to women living in some rural and panic attacks.” and remote communities as they may be the only point of health care access in their community (Shaw, 2006). They may also provide women seeking abortions with a level of safety that Discussion can be jeopardized by protesters at freestanding abortion clinics. Yet women may wish to avoid hospital-based abortion Mapping the data on women's journeys to freestanding services because of confidentiality issues, particularly in smaller abortion clinics raises four important concerns about spatial centers, or because of the multiple appointments, use of general disparities in abortion access in Canada: 1) the paucity of anesthesia and dearth of counseling services involved (Shaw, services outside urban centers; 2) the existence of substantial 2006). Anti-abortion hospital staff may also deliberately access gaps, particularly for women living in Atlantic, Northern mislead women about the availability of local abortion services and coastal communities; 3) the burdensome costs of travel or take a judgemental approach to women seeking abortions C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62 59

Fig. 5. Regional map of women's travel patterns to abortion clinics — Maritimes.

(Shaw, 2006). Furthermore, hospital-based abortion services 2007). PEI, another Atlantic province, can be considered in are usually provided in a surgical suite, meaning that wait times direct violation of the Canada Health Act because of its can be lengthy as other surgical procedures are given priority government's refusal to fund abortions within the province (Dube, 2007). Although abortion clinics are located in urban through public health care. Clearly some women must travel centers, the clinic model tends to lead to shorter wait times, less because of a scarcity of abortion services close to home. While invasive procedures and sympathetic staff. It also provides cost provincial and territorial governments provide financial assis- savings to the health care system and allows for onsite tance for patients who must travel outside their home counseling and contraceptive provision (Norman, 2011). communities to access various medical services, similar support There are substantial regional gaps in access to abortion generally does not exist for women travelling for abortions (see services. Women in the Atlantic provinces of Newfoundland exception for Aboriginal women below). However, there is a and Labrador, Nova Scotia, Prince Edward Island (PEI), and New general sense that women will not complain about waiting or Brunswick have the lowest access to abortion services in the travelling for access to abortion services as long as they are able country while women living in Canada's rural, Northern and to get access (Nykiforuk & Flaman, 2011). Thus the stigmatized coastal communities are also underserved, compounding social nature of abortion services clouds all policy discussions. disparities that already exist. Research has consistently shown The majority of the women accessing clinic abortion that young people living in rural and Northern communities services are in their mid-twenties and have low income, have poorer sexual health outcomes, such as sexually trans- compounding the burden of paying out of pocket for mitted infections and inadequate access to sexual and repro- abortions and/or associated travel costs. These women are ductive health services (Deering, Tyndall, & Koekoorn, 2010; also most likely to fall through the cracks created by the Maticka-Tyndale, 2007; Shoveller, Johnson, Prkachin, & Patrick, federal government's reluctance to enforce the principles of 2007). Data also suggest that the proportion of sexually the Canada Health Act and rarely feature in policy discus- experienced youth is higher in Newfoundland and Labrador sions. Abortion is one of just 16 medical procedures exempt and New Brunswick as compared with the national average, from the “portability” requirement permitting reciprocal pointing to a real need for a range of accessible sexual and billing when the procedure is obtained outside of their reproductive health services including sex education, contra- province of residence with their home province health ception and abortion (Canadian Federation for Sexual Health, coverage. This restriction is particularly critical for students 60 C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62

Fig. 6. Women's travel patterns to abortion clinic by age. who often live outside their home province while attending women must endure a formal approval of funds system for university or college and because they are temporary off-reserve travel or else must pay for their own travel residents in that province or territory, are not required to expenses (Smith, 2010). This system can create lengthy obtain new health coverage. In practice, some provinces have delays and confidentiality is difficult to maintain. However, set up ad-hoc agreements to pay for services in a neighboring accessing an abortion outside this system is an even greater province but this is not system wide. Removing abortion challenge (Government of Northwest Territories, 1992; Smith, from this list of exempted services is a simple policy change 2010). that recognizes the porous nature of Canada's provincial and This study had three main limitations. First, due to the territorial borders and provides support for the women who nature of the questionnaire distribution at each clinic a total have to travel outside of their home community to access response rate could not be calculated. It is possible that the abortion services. women who participated in this study are not representative of Finally, the data reveal that First Nations and Métis women, the population at each clinic as a whole. Second, this study particularly those living in rural and remote communities, face focused solely on freestanding abortion clinics. Therefore, we several intersecting barriers to accessing abortion services. did not gather information about women who accessed Forty percent of Aboriginal people in Canada live on reserves, abortion services at hospitals or the reasons why women with 60% living off reserve in communities of various sizes bypassed them in favor of those offered at freestanding (Statistics Canada, 2008b). The establishment of reserves, along abortion clinics. Other Canadian studies have focused specifi- with residential schools and a classification system for “Indians” cally on hospitals indicating that the abortion services they under the Indian Act (1876) has resulted in a negative health offer are difficult to access (CARAL, 2003; Shaw, 2006). A study legacy for Aboriginal women (Bourassa, McKay-McNabb, & that combines women's travel to access hospital- and clinic- Hampton, 2004). Reserves are most often located in rural, based abortion services would be a valuable future endeavor. remote or Northern communities. The women who self- Finally, we are unable to determine if particular groups identified as First Nations and Métis were almost three times (e.g., younger women; unemployed women; First Nations as likely to report travelling more than 100 km to access women) are overrepresented in our sample due to the poor abortion services, suggesting that they do not reside in urban quality and lack of similar comparable detail in Canada's centers. In addition to the complications of distance, Aboriginal national abortion statistics. C. Sethna, M. Doull / Women's Studies International Forum 38 (2013) 52–62 61

Conclusion Final Report of the Commission on the Future of Health Care in Canada (2002). Building on Values: The Future of Health Care in Canada. Fowler, Dawn, & Trouton, Konia J. (2000). Should abortion reporting continue This first-time national study on Canadian women's travel to in Canada. Canadian Journal of Public Health, 91(5), 396. freestanding abortion clinics is an illustrative example of spatial Geraghty, Estella M., Balsbaugh, Thomas, Nuovo, Jim, & Tandon, Sanjeev (2010). Using geographic information systems (GIS) to assess outcomes disparities in regard to abortion access. The maps provide disparities in patients with Type 2 diabetes and hyperlipidemia. Journal convincing visual evidence that women living in Canada's rural, of the American Board of Family Medicine, 23,88–96. Northern and coastal communities are underserved. Therefore, Gober, Patricia (1994). 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